WHEELING, W.Va. -- Here's how people can earn a notation of "difficult patient" on their charts.

WHEELING, W.Va., June 23 -- Gauged by the popularity of physician-rating Internet sites such as Healthgrades.com, patients love to trash their physicians for cold personalities -- or just cold hands.

But it's a two-way street. Patients also can do things to make the doctor's job needlessly difficult, sometimes to the patients' own detriment, and definitely to the doctor's annoyance.

A frequently cited 1999 study in the Archives of Internal Medicine found that doctors rated up to 15% of patient visits "difficult."

Many doctors run into patients with bad habits, which makes diagnosing and treating them seem maddening.

The following is a collection of patients' top doctor-irking habits, as suggested by studies and conversations with practicing physicians.

Frustration No. 1: Meddling Families in the Room

The first time a young person goes into the checkup room alone can be a rite of passage, of sorts. But a small percentage of adults never take that step.

About 16% of all patients bring a companion -- a spouse, adult child, parent, or friend -- to their doctor's appointments, according to a 2002 study in the Journal of Family Practice.

While many find that the comfort and support helps them through their appointment, the crowd can sometimes interfere with a doctor's work or a patient's well being.

"You get a husband and wife in a room, and one is overweight and one of them is not, and the other starts saying, 'See, I told you so,' if you talk about weight," said Keith Ayoob, EdD, a nutrition and obesity specialist at Albert Einstein College of Medicine in New York City.

Such distractions may impede the doctor's ability to communicate, or the patient's ability to discuss his or her symptoms.

Sharon Hull, MD, MPH, and Karen Broquet, MD, both of Southern Illinois University, offered this advice regarding companions in the doctor's office in the June 2007 issue of Family Practice Management.

"When patients have companions in the exam room, be sure to speak directly to the patient, avoid taking sides in any conflict, and evaluate all parties' understanding of the information and the management plan," they wrote.

Drs. Hull and Broquet also suggested steps to determine whether the patient actually wants the companion present or feels manipulated into bringing the person along.

Frustration No 2: Keeping Mum about the Herbs

When it comes to most herbal supplements, the medical community and the general public may, indeed, have reached a fragile consensus -- namely, that these remedies do not count as drugs.

Doctors often discount the effectiveness of herbal supplements, and patients often believe that the so-called natural origin of these preparations sets them apart from other medications.

But when it comes to drug interactions, doctors want to know what supplements their patients are taking -- and patients aren't always willing to fess up on their own.

"Often, if they don't tell you what supplements they're taking, it's not until the point that they have a potentially serious reaction that you know they're taking one that might interfere with their other drugs," said John Sutherland, MD, director emeritus of the Northeast Iowa Medical Education Foundation.

One example he cited is St. John's wort, an herbal supplement available over the counter for mood improvement. He said the supplement has the potential to interact with certain antidepressants the patient might be taking for the same condition.

"We try to do a good job when these patients come in for visits . . . to try and find out what OTC medicines they are taking, as well as medications that they may have received from another physician," he said. "But they aren't always forthcoming about this."

The consequences can be frustrating to doctors and dangerous for patients. Dr. Sutherland said that most patients who take these herbal supplements do so on the recommendations of friends or family, and they don't necessarily tell their physicians when they start doing so.

"Fortunately, most of these things that people take have limited evidence of value, and so most of the time they don't hurt them either," Dr. Sutherland said.

But the guesswork involved when patients don't come clean about the herbal OTCs they are taking often makes for a major headache.

"These kinds of things, to me, are far more problematic and frustrating than people who don't adhere to lifestyle recommendations," he said.

Frustration No. 3: Quitting Medication Without Notice

Just as doctors would like to know all of the medications, herbs, and supplements you start, they also like to know when you stop taking your medicine.

One of Dr. Sutherland's top bad behaviors by patients is when they "discontinue medications because of adverse reactions or expense but don't let you know about it until they come in with problems again."

Sutherland cited two examples this week of patients on medication for high blood pressure who decided to tamper with the doses at home, with no notice to their doctors.

"One had diabetes and hypertension, and she had cut her medications in half," Dr. Sutherland said. "Consequently, her blood pressure had gone way above the goal for diabetes. She did not have many complications from [the medication], but she, on her own, decided that it would be good for her to cut back on that.

"Another patient had stopped a diuretic she used with a blood-pressure medication, just because she didn't like the side effect of more urination during the day," he said. "When she came in, her blood pressure was over 200."

Dr. Sutherland said most patients do inform him when they have unwanted side effects or problems with medication, but it also isn't unusual for people to keep mum until months later.

Patients who stop their medications can cause headaches for more people than just their doctors.

People who stop prescribed antibiotics before they've finished the course may only kill the most susceptible microorganisms, allowing more resistant strains to survive and infect others.

Mood-altering medication can also be dangerous to quit without a doctor's consultation. Benzodiazepines, in particular, now come with a warning against abrupt discontinuation.

The FDA has identified more than 40 adverse effects associated with abrupt withdrawal of these agents, including headache, anxiety, tension, depression, insomnia, confusion, dizziness, "derealization" and short-term memory loss.

Frustration No. 4: Change My Lifestyle? Must Be a Pill for That

Most physicians recognize that recommendations about lifestyle frequently go unfollowed. Nevertheless, patients who seemingly refuse to do anything about their obesity leave many doctors frustrated.

"I sometimes feel like patients are telling me they want me to make them stop bleeding, but without pulling out the arrows stuck in their chests," said Lee Green, MD, MPH, professor of family medicine at the University of Michigan in Ann Arbor.

Obesity can lead to diabetes, high blood pressure, heart disease, and arthritis -- especially in the knees, according to the National Institute of Diabetes and Digestive and Kidney Diseases. Yet losing just 10% of a person's body weight can delay or prevent some of these diseases.

"The most frustrating thing for me is patients whose lifestyle is making them miserable but they won't change it," Dr. Green said.

He said many problems, such as sleep apnea and chronic tiredness, can be attributed to eating too much and moving too little. In that case, the treatment isn't disease, but "lack of health."

"[It's] people whose knees are killing them, because they're 80 pounds overweight, and they're dead set on the idea that the fix is a drug, or an injection, or surgery," he said.

"I'm in good shape, pretty fit, and my knees hurt after a day of hiking with a 50-pound pack. These folks are carrying more weight than that, lugging it 24/7, and they weren't fit to start with," Dr. Green said. "Why do they hurt? Hmm, not a major medical mystery . . ."

Frustration No. 5: Hi Doc, I Need a Prescription for . . .

The U.S. is one of the few countries in the world that allows direct-to-consumer drug advertising. Since the FDA's 1997 decision to let drug companies market pharmaceuticals to the masses (previous drug marketing was aimed largely at physicians), doctors have reported more patients asking about drugs than ever before.

In some cases, it might be helpful. But doctors say patients who are simply sold on a drug can interfere with their own care.

"For me, what is most frustrating is when patients view doctors as simply a source of a signature for something they want, without really wanting the physician's guidance or opinion," said Thomas Schwenk, MD, chairman of family medicine at the University of Michigan.

In fact, in a recent study in Archives of Internal Medicine, insistence on an unnecessary drug was physicians' most common complaint about their patients.

But Dr. Schwenk said his concern does not extend to patients who come in with questions based on what they've seen on television or read on the Web.

"I don't mind when patients do their own research on the Internet; I actually value it, as long as their purpose is to be informed so they can engage in complex discussions and decision-making," Schwenk said.

Frustration No 6: I'll Take a CT Scan, MRI, and Strep Test, Please

Although not quite as common as patients who demand medicine the doctor would not otherwise prescribe, doctors say plenty of patients also demand extra tests and procedures.

"This is the bias some patients have to just doing more, without any understanding of how more care is not only expensive, but actually often leads to complications, poor outcomes, and lower quality," Dr. Schwenk said.

Many patients who demand a specific test might have had bad experiences with a doctor in the past, or may be going through life stressors. There are many other reasons, including psychological problems such as borderline personality disorder, according to Drs. Hull and Broquet in their Family Practice Management article.

Yet while much ink is spilled on how to deal with the difficult patient, most doctors understand it's not about them.

"Who cares? The patient is the center of care, not the physician," said Scott Fields, MD, vice chairman of family medicine at the Oregon Health and Science University in Portland.

"This is part of what is wrong with how we provide care," he said. "We need to be much more worried about why the patient does what he/she does and much less about how it affects us."

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